VHA examination of surgical errors find poor communication most common culprit

Patient Safety Monitor Insider

December 16, 2009

Poor communication was the most common cause of wrong-site, -side, and -person, surgeries at the Veterans Health Administration (VHA), reports American Medical News. According to a study published in the November Archives of Internal Medicine, 21% of errors in surgery resulted from inadequate communication practices, although the overall number of errors examined was only one per 18,955 surgeries (some errors go unreported, so a definite rate of wrong surgeries could not be established).

The study looked at incidents of error in surgery from 2001 through 2006. The VHA implemented a process to prevent wrong surgeries in 2003, similar to the Universal Protocol, which requires that those caregivers involved in surgery verify the patient prior to surgery, mark the surgical site, and perform a timeout just prior to the procedure. There were no adverse events reported in surgeries when this process for was used, said the authors of the study.

To read more from American Medical News, click here.